Procedure of extended hilar bile duct resection and its application for hilar cholangiocarcinoma

Background/Aims: Several surgical procedures from hilar bile duct resection to hepatectomy have been adopted for hilar cholangiocarcinoma. However the details of the surgical procedure and the indications for hilar bile duct resection have not been determined. Methodology: Pathohistological outcome of resected specimens in five patients undergoing extended hilar bile duct resection was reviewed and compared with 12 patients undergoing partial hepatectomy with caudate lobectomy. Results: Extended hilar bile duct resection was used for older patients, cases of choledochal site and less invasive tumor. The mean lengths of the left hepatic duct (21.7+/-7.8mm) and the anterior hepatic duct (18.0+/-3.2mm) in the specimens resected by extended hilar bile duct resection did not differ from those seen in right and left hepatectomy, respectively. Furthermore, extended hilar bile duct resection removed partial caudal hepatic duct. However the length of the posterior hepatic duct removed by extended hilar bile duct resection (14.3+/-2.0mm) was significantly less than that excised in left hepatectomy (19.3+/-6.6mm) (P<0.05). The histologic positive margin rate of the extended hilar bile duct resection group (40%) was the same as that of the hepatectomy group (50%). Papillary or nodular form tumor tended to have positive ductal margins in both surgical techniques. On the other hand, flat tumor tended to have high positive rates in both ductal and excisional margins even in hepatectomy. Two cases with positive surgical margin died of local recurrences, however another 3 cases with negative surgical margin are alive without recurrences from 8 to 20 months after surgery. Conclusions: The indication of extended hilar bile duct resection for hilar cholangiocarcinoma is Limited to cases in which the infiltration is confined to the hepatic bifurcation, such as type I and type II of Bismuth classification with regard to papillary and nodular macroscopic appearance.